‘Early-maintenance’ facelift catches aging problem before advanced issues arise

By:  Rochelle Nataloni

• Early-aging deformity is characterized by subtle but distinct sagging of deep facial tissue, loss of facial contour
• Early-maintenance facelifts include SMAS repositioning of the midface, cheek and jowl; minimal or no skin tension; some form of forehead, neck and eyelid surgery

Patients who desire the benefits of an early-maintenance facelift want to stop the clock at a time when they feel they look their best, says Timothy J. Marten, M.D.

“It’s also a common misconception that all patients seeking surgical facial rejuvenation want to look as young as possible,” says Dr. Marten, director and chief of the Marten Clinic of Plastic Surgery in San Francisco. “In fact, many patients think they look their best in the third and fourth decade of their lives.”

Traditionally, facelifts were reserved for older patients and regarded as a way to “repair” an advanced aging deformity, Dr. Marten says. But today, many patients are requesting procedures to rejuvenate the face at a younger age, all with the goal of maintaining — not regaining — a youthful appearance.

Early-aging deformity is characterized chiefly by a subtle but distinct sagging of the deep facial tissue and loss of facial contour that is typically evident as perioral laxity, jowl formation and cheek flattening, Dr. Marten says. Varying degrees of forehead ptosis and loss of neck contour are also usually present, but skin wrinkling, skin laxity and skin redundancy are usually minimal.

“Although the early-aging deformity of the face has been overlooked and underappreciated by all but the most observant and artistically sensitive plastic surgeons, it has been recognized by and has been a cause of concern for many of our patients for some time,” he says.

A NEW PARADIGM
Early-maintenance facelifts typically include SMAS repositioning of the midface, cheek and jowl; minimal or no skin tension; a precise incision plan and meticulous execution of skin excision closure; and some form of forehead, neck and eyelid surgery, Dr. Marten says. Skin resurfacing is not usually needed and fat injections are generally not indicated, although they are sometimes helpful because “the younger patient typically has minimal skin wrinkling and facial atrophy,” he says.

The early-maintenance facelift approach is based on the concept that aging is a continuum and that younger patients have a microform of the same problems older patients have. Thus, they should be treated by more or less the same means, but the procedures must be performed less aggressively and in a very meticulous fashion.

“Patients with forehead ptosis are often best served with a forehead lift even if the ptosis is modest; patients with sagging of the cheek and jowl and loss of a smooth jawline need a facelift that includes SMAS support to correct these problems if a meaningful and sustained improvement free of secondary deformities is to be obtained; and patients with neck problems often are not adequately or attractively rejuvenated with liposuction or by limited surgical or nonsurgical means,” Dr. Marten says. “Skin resurfacing, ‘skin shrinking’ and facial filling may be of help but don’t actually address these problems.”

Dr. Marten says it can be difficult to define exactly what constitutes an “early” facelift because some patients in their 40s are already “emergencies,” while other patients in their 50s could arguably be defined as undergoing early procedures.

“As a general rule, I would say most surgeons regard a patient to traditionally be ready for a facelift and related procedures in their 50s or 60s, and that an ‘early’ facelift would be one performed in one’s 30s or 40s,” Dr. Marten says. “We don’t track numbers specifically, but the average age of facelift patients in our practice is early-to-mid 40s.”

SCAR SUBTERFUGE Concealing scars is of paramount importance in the young patient, Dr. Marten points out. “If we see a bit of a scar on a 60- or 70-year-old we smile to ourselves and think ‘she’s had a facelift,’ but typically don’t pass judgment or cast aspersions on her. If we see a scar on a 30- or 40-year-old, however, this somehow carries more of a stigma. In this sense, operating on a younger patient arguably carries a heightened responsibility. There is no room for error, and every effort must be made to obtain a well-concealed scar,” Dr. Marten says.

“The fallacy of most ‘short scar’ procedures is that they move the scar from a concealed location behind the ear to a much more visible and objectionable location in front of the temporal hairline,” he adds. “While this is often a necessary and worthwhile compromise in the older patient, it is a considerable burden to the younger patient who wears less makeup, leads a more active lifestyle, and who is subject to more shame when this scar is seen by others.

“The ‘early-maintenance’ technique, by comparison, avoids a scar along the temporal hairline,” and the scar behind the ear is situated in a way that allows the patient to wear her hair up or back, or in a ponytail, he says.

The second problem with most short scar techniques is that little, if any, meaningful and sustained support from deep-layer tissues is obtained, and unavoidable skin tension incites hypertrophic healing and poor scar formation. “This is avoided when a full SMAS lift is performed and tension is diverted from the skin to the SMAS layer,” Dr. Marten says. “Finally, most proponents of mini-lifts and short scar procedures view the fact that they can be completed quickly as an advantage to both the patient and surgeon, but in reality, this rushing through the procedure is the typical source of a low quality, poorly situated and poorly concealed scar in many cases.

“In an early-maintenance procedure, 45 minutes or more is often spent concealing the scar on each side, totaling an hour and a half on that part of the procedure alone,” Dr. Marten says. “Many surgeons performing mini-lifts and short scar procedures are trying to complete the entire facelift in that same amount of time. Ultimately, it is incumbent on surgeons performing facelift procedures to remember that it is someone’s face we have been entrusted with, and that it deserves our best effort, not a compromised or half-hearted one.”

Dr. Marten says that patients who have early-maintenance procedures typically recover quickly and can return to their work and social lives in 10 to 14 days. This is due to the fact that they are young and heal well, as well as the fact that pull was placed on the SMAS and not the skin and that the patients have well-concealed incisions (no incision along the temporal hairline).

In addition, they typically don’t need fat injections or skin resurfacing, both of which increase swelling and prolong recovery. “Ultimately, however, no one judges a facelift by how long it took to perform or how fast the patient recovered,” Dr. Marten says. “In the end, what is remembered and what really matters is that the patient looks natural and has no signs that surgery has been performed.”

LESS IS RARELY MORE The “early-maintenance” concept is not limited to just the cheeklift, as are some minimally invasive procedures. “The whole face ages — not just part of it — even in younger patients,” Dr. Marten says. “To achieve a balanced, harmonious and natural appearance, the forehead, eyes and neck often have to be refreshed using a ‘combination’ approach. This is the inherent weakness in any attempt to spot-rejuvenate or refresh the face in a limited way — one part of the face can end up looking younger than the others, and this is something that subliminally, at least, suggests to others that something has been ‘done’ or ‘is not right.’ It is a bit of a paradox and can be difficult to accept at first, but skillfully performed, doing more surgery can actually look more natural … because a balanced and harmonious outcome is achieved.”

Dr. Marten stresses that the early-maintenance technique is not new, but it is also not something that can be adopted by the surgeon performing the occasional facelift.

“The early-maintenance concept is not new or a specific technique of mine,” Dr. Marten says. “A committed group of skilled surgeons have used or are employing a similar approach. However, I published one of the first detailed and comprehensive scientific articles on the technique and the concepts behind it, and as such it has served as a point of reference for surgeons seeking to meet the increased demand we have seen for early-maintenance procedures.

“It has also provided important counterpoint to the often-misguided and overly simplistic approaches advocated by those asserting that the younger patient can be effectively treated by nonsurgical or limited surgical means,” he says.